Transjugular intrahepatic portosystemic shunt (TIPS): the anesthesiological point of view after 150 procedures managed under total intravenous anesthesia.

TIPS is a percutaneous procedure which diverts blood from the portal to the systemic circulation preventing rebleeding from varices and stopping or reducing the formation of ascites. The choice of the anaesthetic technique is still a matter of debate. Since January 2003, 150 consecutive TIPS were performed using total intravenous anesthesia (TIVA), (propofol/fentanyl or remifentanil), endotracheal intubation and mechanical ventilation. Sixty-one patients were classified as ASA 2, 73 ASA 3, and 16 ASA 4. According to CHILD classification, 96 patients were in Class A, 48 in Class B, 6 in Class C. Mean duration f the procedure was 100+/-62 min. After TIPS placement Portal vein pressure decreased from 30+/-10 to 14+/-4 mmHg while RAP increased from 8+/-4 to 12+/-6 mmHg. Intraoperative fluid management included mainly crystalloids (750+/-200 ml, 5.4+/-1.5 ml/kg/h). Fresh frozen plasma (median 2 units, range 1-3) was given in 20 patients (13%) if PT INR was >2. Packed red cells (median 2 units, range 1-5) were transfused in 35 patients (23%) to keep haematocrit >25%; platelets were administered before the procedure if platelet count was <50,000x10(-9) (20 patients, 13%). Urine output was kept above 4 ml/kg/h with loops diuretics (mean diuresis 700+/-200 ml, 5+/-1.5 ml/kg/h). Ten patients (6.6%) required ICU after the procedure, because of intraoperative hemodynamic instability. Three patients (2%) died in the early postoperative period because of multiple organ failure associated with the acute deterioration of an already marginal hepatic function.

Indocyanine green kinetics to assess liver function: Ready for a clinical dynamic assessment in major liver surgery?

Indocyanine green (ICG) kinetics (PDR/R15) used to quantitatively assess hepatic function in the perioperative period of major resective surgery and liver transplantation have been the object of an extensive, updated and critical review. New, non invasive bedside monitors (pulse dye densitometry technology) make this opportunity widely available in clinical practice. After having reviewed basic concepts of hepatic clearance, we analysed the most common indications ICG kinetic parameters have nowadays in clinical practice, focusing in particular on the diagnostic and prognostic role of PDR and R15 in the perioperative period of major liver surgery and liver transplantation. As recently pointed out, even if of extreme interest, ICG clearance parameters have still some limitations, to be considered when using these tests.